Eating Disorders Coalition
Friends of the EDC Registration Form
Friends of the EDC: $100
Contact Information:
E-mail Address:
First Name:
Last name:
Address :
Address (Line 2):
City:
State:
Zip:
Phone:
(optional) Company:
_____
(optional) Title:
_____
How did you first learn about the Eating Disorders Coalition?:
 A presentation or briefing by the EDC
 A story in the media (print broadcast or online)
 A treatment program for medical or mental health
 An email that I received
 Another nonprofit organization
 Internet search
 Word of mouth (friend, family member or coworker)
 Other
How would you best describe yourself?:
 Family member or friend of someone who has had an eating disorder
 Person who has or has had an eating disorder
 Member of US House or US Senate or staffer
 Treatment professional or administrator
 Researcher
 School employee (K-12)
 Student
 Other
Ideas, comments, or ways you want to be involved:
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_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
_____________________________________________________________________________________________________________________________ _________________________
Payment Information:
Payment Type (Circle One): Credit Card / Check
Name on Card:
Credit Card #:
Credit Card Type: American Express / MasterCard / Visa
Expiration date:
/
Security Code:
Billing Address (if different):
Billing Address (Line 2):
City:
State:

YES, I would like my name listed on the EDC website.

NO, I do not want my name listed on the EDC website.
Zip:
Please send completed forms to:
[email protected]
or
EDC
P.O. Box 96503-98807
Washington, D.C. 20090